Old n' Busted: 40M covered by the #ACA. New Hotness: 45M covered by the ACA.

Last spring, I noted that total enrollment in healthcare policies either specifically created by or expanded to more people by the Affordable Care Act had broken 40 million Americans:

Across these 19 states alone, ACA Medicaid expansion enrollment is up 788,245 people since last March, or 6.7% overall. If you remove Missouri and Oklahoma, it's still up 4.28% since then, and again, this is still as much as 8 months out of date depending on the state. Assuming Illinois is wrong, removing it as well puts expansion enrollment up 5.4% since last March.

Assuming these states are representative, it's safe to assume that Medicaid expansion is up at least 4.3% nationally since March 2022, or around an additional 960,000 people. If you go with the higher end estimate (+5.4%), it would be up over 1.2 million nationally.

That puts the grand total at somewhere between 39.9 - 40.1 million people with ACA-enabled healthcare covered nationally.

After Congressman Jim Clyburn tweeted out praise for the  21 million Americans now being insured under the ACA under the Biden Administration the other day, I figured that it'd be a good time to take another look at where things stand for ACA enrollment overall.

Last week I noted that CMS had released a new effectuated ACA exchange enrollment report touting a record-breaking 20.8 million Americans enrolled in active exchange-based Qualified Health Plans (QHPs) as of Feburary 2024, which is presumably where Rep. Clyburn's number comes from. Fair enough; the exact total was 20,777,786.

However, there's still two other big numbers missing from that figure: Basic Health Plan (BHP) enrollees and ACA Medicaid expansion.

As of May 2024, New York State of Health reported 1,368,234 enrollees in their Essential Plan (NY's name for their BHP program). Meanwhile, Minnesota is reporting 100,199 enrollees in MinnesotaCare as of July.

That brings the total up to 22,246,219 people so far.

Next, we need to add Medicaid Expansion enrollees.

The most recent official Medicaid/CHIP enrollment data available for all states comes from the monthly Medicaid & CHIP Enrollment Trend Snapshot reports via CMS. The most recent of these is from March 2024, which isn't too out of date...except that these reports (as well as the raw determinations / enrollment data which they're based on) don't separate out "Group VIII" (ACA Medicaid Expansion) enrollees, making them useless for my purpose today.

For that, the most comprehensive data comes from the quarterly Medicaid & Budget Expenditure System (MBES) reports, which separate out VIII Group enrollees, and even breaks those out between those newly eligible for Medicaid specifically due to ACA expansion as well as those who would have already been eligible for Medicaid prior to the ACA but who enrolled thanks to the ACA dramatically streamlining the enrollment process.

The only problem here is that the MBES reports only run through September 2023, at which point the national ACA expansion total stood at 23,225,220.

We're up to 45,471,439 Americans with ACA coverage.

Here's where things get a bit fuzzy. The BHP data is about as up to date as you can reasonably expect, but the exchange QHPs are still 5 months out of date and Medicaid expansion data is 9 months old. Normally that wouldn't make too much of a difference but with the ongoing Unwinding process the needle has probably moved a bit:

  • Medicaid expansion in most states has likely dropped by several hundred thousand since September due to Unwinding

If you assume NC's expansion has effectively cancelled out Medicaid enrollment reductions in every other state since last fall, it still places the grand total at somewhere north of 45.4 MILLION Americans with ACA-enabled healthcare coverage.

I should also note that there's likely another 2 - 3 million people enrolled in OFF-exchange individual market Qualified Health Plans, all of which are unsubsidized. You can argue as to whether or not these should "count" as being "ACA-enabled coverage" since the individual market already existed prior to the ACA, but the ACA required that these medical policies be significantly improved in terms of comprehensiveness and to have the same regulations as exchange-based policies including guaranteed issue, community rating, removal of annual/lifetime limits, maximum out-of-pocket cost caps and so forth.

If you count these, that puts the grand total of "ACA healthcare coverage" at somewhere around 47 million or so.

It's also worth noting that when you include all three categories, 14 years after it was signed into law by President Obama, the Affordable Care Act is now in the same ballpark as Medicare and Medicaid in terms of total healthcare coverage share of the population:

  • ACA exchange QHPs + BHPs + Medicaid expansion combined cover around 45.5 million Americans, or perhaps 47 million with off-exchange QHP enrollees included.